Worker’s Compensation Forms

Workers’ Compensation provides eligible workers who are either injured or who become ill during the course of employment with medical coverage and, if applicable, disability coverage. The program is legislated by State law. The City’s self-funded Workers’ Compensation program is administered by LWP Claim Solutions, Inc. (LWP).

1. Worker’s Comp Claim Form (Turn in to HR -ASAP)
2. Employers Report of Occupational Injury or Illness – Form 5020 (Turn in to HR -ASAP)

• LWP- Memo to All Employees
  • Workers’ Compensation Policy
  • Industrial Injury Medical Panel
  • Predesignation of Personal Physician
  • Statement to Treating Physician
  • Worker’s Comp Claim Form
  • Employers Report of Occupational Injury or Illness – Form 5020
  • Safety Report Instructions & Safety Report Forms
    • Safety Report 
    • Safety Report Instructions 
    • Safety Action Report
    • Safety Action Report Instructions 
  • Workers Comp FAQ’s
  • Cal Osha Reporting Requirements

RU-91 forms

• Job Descriptions

LWP Claims Solution, Inc.
PO Box 349016
Sacramento, CA 95834-9016
T: (800) 565-5694
Fax: (408) 725-0395
Email: Info@lwpclaims.com